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How MIPS, APMs Work Under MACRA to Improve Value-Based Care

A health IT consultancy has released a guide on how MIPS and APMs will reimburse eligible clinicians for value-based care under the proposed MACRA rule.

By Jacqueline Belliveau

- While CMS highlights how the proposed MACRA rule is more streamlined than previous value-based care programs, many healthcare providers are still trying to digest the potential changes to Medicare reimbursement starting in 2019.

Proposed Medicare reimbursement models under MACRA change value-based care for clinicians

In an attempt to navigate the complexities of MACRA, Impact Advisors released a guide on how eligible clinicians would receive value-based reimbursements in 2019 based on their performance in 2017.

The health IT consultants noted that clinicians may want to understand MACRA as soon as possible since the final ruling is expected to be released in the fall of 2016. This gives eligible clinicians a couple months to prepare for the performance period starting in 2017.

Under MACRA, CMS would implement the Quality Payment Program, which allows clinicians to participate in the Merit-Based Incentive Payment System (MIPS) and an Alternative Payment Model (APM).

MIPS would streamline and consolidate current Medicare incentive programs, such as meaningful use and the Physician Quality Reporting System, and adjust Medicare reimbursements based on a performance score.

READ MORE: How Value-Based Care Looks Under the Quality Payment Program

According to Impact Advisors, only ambulatory physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists are eligible to participate in the first year of MIPS. As the program goes on, CMS intends to expand the eligibility requirements.

However, some eligible clinicians could be exempt, including clinicians who recently enrolled in Medicare, clinicians who treat less than 100 Medicare beneficiaries or have less than $10,000 Medicare charges, and clinicians who participant in an Advanced APM.

Through MIPS, participants would receive a payment adjustment for Medicare reimbursements, noted Impact Advisors.

“The maximum ‘payment adjustment’ would start at +/- 4 percent of Medicare reimbursement in 2019 and would increase to as much as +/- 9 percent in 2022 and beyond,” explained the guide. “In the first five years of the program, there would also be an additional bonus payment for ‘exceptional performance’ available to providers in the top 25 percent. That additional bonus is capped at 10 percent per eligible clinician.”

MIPS Payment Adjustments by Year, Impact Advisors

Despite value-based adjustments, MIPS is stipulated to be budget neutral, which indicates that positive adjustments will need to be balanced by negative adjustments. CMS proposes that about half of participants would receive incentive payments in 2019, while the other half would face penalties.

READ MORE: Will MACRA Implementation Unfairly Affect Small Practices?

Therefore, a clinician’s reimbursements would be relative to the average performance score for all MIPS participants.

Payment adjustments would be calculated using the composite MIPS score, which weighs quality, participation in Advancing Care Information, clinical improvement, and resource use.

MIPS Composite Score Performance Weights, Impact Advisors

The quality portion of the score accounts for 50 percent in the first year, but it is expected to decrease to 30 percent by the third year. CMS designed the section to be more flexible for participants by allowing them to choose what quality measures to report.

The Advancing Care Information category represents 25 percent of the composite score and it replaces meaningful use. Eligible clinicians would report on six current meaningful use measures and they have the potential to earn additional points for measures that improve patient engagement or HIE.

Impact Advisors reported that more healthcare providers would be required to report on meaningful use under MIPS because “eligible clinician” encompasses more specialties than the previous participant term, eligible professional.

READ MORE: Physician Readiness for MACRA Implementation Found Wanting

Under the clinical practice improvement portion, clinicians would report on a quality improvement activity for a chosen 90 days during the performance period. It accounts for 15 percent of the aggregate score.

The resource use category would make up 10 percent of the score in 2019 and would increase to 30 percent by 2021. The score would be calculated using Medicare claims, so eligible clinicians would not have more reporting requirements, explained the guide.

The other value-based model in the proposed Quality Payment Program is the APM program, which also includes Advanced APMs.

For clinicians in a regular APM, CMS would boost their scores in certain MIPS categories and, therefore, increase their payment adjustment.

An Advanced APM must demonstrate the use of certified EHR technology, make quality-based payments, and necessitate that participants bear some financial risk.

“Clinicians with ‘significant’ participation in Advanced APMs in a given year will be exempt from MIPS and will receive an additional 5 percent Medicare bonus for the corresponding payment year,” wrote Impact Advisors.

To qualify for the bonus in 2019, participants must treat 20 percent of patients or make 25 percent of payments through the Advanced APM. The participant requirements are expected to increase as MACRA matures, which may make it harder to actually benefit from the Advanced APM payment model, explained the guide.

Requirements for Participation in Advanced APMs, Impact Advisors

In the first two performance years, specific programs are considered the only Advanced APMs, including the Medicare Shared Saving Program (Tracks 2 and 3), Next Generation ACO Model, Comprehensive ESRD Care, Comprehensive Primary Care Plus, and the Oncology Care Model Two-Side Risk Arrangement.

By the 2019 performance period, CMS intends to expand the Advanced APM list to include non-Medicare APMs.

With an ever-changing healthcare system, providers and policymakers are constantly wondering how to tie quality care to reimbursement structures. Healthcare providers might want to invest more time in learning about the proposed value-based payment models as MACRA could be reality by the end of the year.

Image Credit: Impact Advisors

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